Re: seniority of doctors I presume you are aware of Jonathon Wyatt's paper 
from last year ?

The Association between seniority of A&E doctor and outcome following 
trauma
Wyatt JP, Henry J, Beard D
Injury, 1999  30: 165-168

Here are a few others though I know some of them are trauma related.  Are 
you specifically looking for early 'medical' interventions  by senior 
people ?


1) Implementation of a two-tier trauma response.
Injury 1998 Nov;29(9):677-83
Ryan JM, Gaudry PL, McDougall PA, McGrath PJ
     Department of Emergency Medicine, Westmead Hospital, NSW, Australia.

In this paper in Injury we showed how effective an ED consultant led trauma 
team could be in the management of patients with stable trauma protecting 
the rest of the hospital and allowing it to continue in patient work 
uninterrupted.

OBJECTIVE: To apply a triage tool to patients on their arrival in the 
emergency department and  determine the efficacy and safety of a two-tier 
trauma response. DESIGN: Descriptive  prospective audit. SETTING: Principal 
urban referral hospital that provides a major trauma service. MATERIALS AND 
METHODS: The triage tool designated a major trauma or stable trauma 
response. A major trauma designation mobilised a multidisciplinary team and 
a stable trauma designation an expedited evaluation by emergency department 
staff. Chi-square test and Mann-Whitney U test were used to compare major 
and stable trauma designations. Triage accuracy was evaluated using outcome 
variables. MAIN RESULTS: 78% of 58 major trauma responses and 30% of 180 
stable trauma responses were admitted. The median injury severity score 
(and interquartile range) of admitted patients was 9.0 (5.0-19.5) for major 
responses and 5.0 (2.0-9.0) for stable responses. The triage tool had a 
sensitivity of 65%, specificity of 87%,  accuracy (appropriate triage rate) 
of 82%, undertriage rate of 8% and overtriage rate of 10%.  CONCLUSION: The 
triage tool adequately distinguished between patients with and without 
major trauma. Undertriaged patients had timely and appropriate referral for 
definitive surgical care and had no adverse outcomes.


2)	This weeks Lancet also has replies to Fiona Leckeys paper from a few 
months ago and are worth reading.  She showed improvement in trauma care 
over the last 10 years associated with an increase  in the seniority of 
doctor attending to the patient as a first responder. (validation for the 
A&E based trauma team)

Lancet 2000 May 20;355(9217):1771-5

                       Trends in trauma care in England and Wales 1989-97. 
UK Trauma Audit
                       and Research Network.

                       Lecky F, Woodford M, Yates DW r

http://www.thelancet.com/newlancet/sub/issues/vol355no9217/article1771.html


3)	Here is another example of how good audit supervised by A&E consultants 
makes for improved service. Peter Freeland published this letter in the BMJ 
recently as a follow up to their recent series about critical incident 
monitoring.  I guess it demonstrates what would currently be considered as 
basic good practice within A&E departments in the UK.:

http://www.bmj.com/cgi/content/full/321/7259/505#resp9

Safety of systems can often be improved

EDITOR We agree with the findings of Espinosa and Nolan's study on reducing 
errors made by emergency physicians in reporting radiographs.1 We work at a 
district general hospital's accident and emergency department that has 
operated an almost identical system for over 10 years, in accordance with 
the British Association of Accident and Emergency's guidelines.2

Key points in our department are the rapid return of all radiographs to the 
requesting physician; the reporting of the radiographs by consultant 
radiologists within 24 hours; the recall of any patients with errors made 
in interpreting radiographs by telephone;
and the use of any such radiographs as a teaching exercise for all staff. 
Differences in the systems include reporting of plain radiographs within 24 
hours in our institution rather than 12 hours, and an additional level of 
input in the marking of radiographs as abnormal by radiographers.

Using the experience of the radiographers adds another tier of safety to 
the system. The radiographer marks all abnormal radiographs with a red dot. 
This part of the system is audited regularly (last audit: sensitivity 93%, 
specificity 97%; audit period two weeks, 449 radiographs; true positive 
results 80, false positive results 6, false negative results 9, true 
negative results 354).

Having such a fail safe system has several effects: patient satisfaction is 
subjectively better, with the knowledge that all radiographs are reported; 
few complaints are made about misinterpretation; and a culture of learning 
and cooperation exists
among junior staff.

Continuous audit data show a remarkably low rate of clinically important 
misinterpretation: 0.64% of plain radiographs per month (mean 6.84 events 
per month, mean 1069 radiographs per month; range 0% (0/1049) to 1.4% 
(16/1151) per month, data from 90 consecutive months). This compares with 
the rate of false negative errors of 0.3% (0.26% to 0.34%) in Espinosa and 
Nolan's study.

This is an excellent systematic approach to what is an error prone 
activity, reducing mistakes by accident and emergency staff (often junior), 
increasing patient satisfaction, and reducing long term patient morbidity 
and litigation. We think that this is the type of approach alluded to in 
another article in the same issue, by Barach and Small, applied in a 
medical context.3

Peter Freeland, consultant in accident and emergency medicine.
St John's Hospital at Howden, Livingston, West Lothian EH54 6PP

 1.
   Espinosa J, Nolan T. Reducing errors made by emergency physicians in 
interpreting radiographs: longitudinal study. BMJ
   2000; 320: 737-740[Abstract/Full Text]. (18 March.)
 2.
   Clinical Services Committee, British Association for Accident and 
Emergency Medicine. X-ray reporting for accident
   and emergency departments. London: BAEM, 1983. (Currently under 
revision.)
 3.
   Barach P, Small S. Reporting and preventing medical mishaps: lessons 
from non-medical near miss reporting systems. BMJ
   2000; 320: 759-763[Full Text]. (18 March.)

I hope some of these are helpful but we do need to perform more research 
that shows what we are doing in A&E at a senior level is reflected in good 
outcomes for patients.

John Ryan







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